Does she look in pain?

NightNerd, MSN, RN · May 20, 2017

It is a kind of goofy question. People who have lived with chronic pain can be excruciatingly uncomfortable and look perfectly calm because they've gotten so used to it. But there are definitely people who show some physical signs of distress, so I would certainly tell the doc if they are a PAINAD of 8, 10, whatever, and explain their behavior (grimacing, crying, restless, etc.). Ultimately, if you can back up your request objectively, great, but that can't be the end-all be-all of the discussion.

AceOfHearts<3 · May 20, 2017

This is the type of crap that really ticks me off. She has stage 4 cancer, probably with mets and is most likely terminal- she has a freaking good reason for being in pain! I can't stand providers that don't take that seriously.

I don't hesitate to tell providers when things don't match up- 10/10 pain yet talking away on the phone, playing on the phone, laughing and being loud with visitors or saying they are in so much pain they can't sleep but every time you round on them they're asleep and they can't stay awake to have a conversation, etc. I really can't stand under treated pain especially when there is a very good and clear reason for it.

I had a patient come up from the ED one time. They were admitted for a PE. They had been in an accident, went home, came back for majorly surgery, went home again, and then ended up with a good size PE. I requested a PCA pump and the freaking resident made some idiotic comment about why is she having so much pain suddenly. I couldn't believe it. I didn't get the PCA pump for the patient, but I didn't hesitate to page (and I hope I annoyed the crap out of that idiot resident) any time I needed more pain meds for the patient. I never got the level of pain control I wanted for the patient, but I got it down some and knew I did my best. I documented out the wazoo too. Guess what the patient had when I was back in for my next shift... A PCA pump! Imagine that

mmc51264, BSN, MSN, RN · May 21, 2017

We have just put in a new pain policy and one of the options is "assume pain present" for non-verbal, or demented pts, or intubated pts that are post-op. We also have scales such as PAINAD and Wong-Baker. There are many ways to assess pain other than have some give you a number between 0-10.

I work on an orthopedic surgical floor and it is assumed that all pts have some sort of pain.

ArtClassRN, ADN, RN · May 21, 2017

What's your thoughts on this question folks?

Well, did she look like she was in pain? The MD was asking you for a specific reason. You reported her prescribed meds were far less than PTA and the patient told you it wasn't touching their pain.

It is your fault for letting the conversation even get to that point, but since you were there, why didn't you say "YES!" Which would presumably get increased pain meds for this patient? Don't have a pissing match with the MD, do what it takes to help the patient.

For instance, what dose did you want the MD to order? Whatever that does is, - ASK for it. You will either get that dose or you will force the on-call say "No."

If you get what you want - great. If you don't, you can document the heck out of the situation, "Informed oncall about uncontrolled pain and asked for . Oncall declined."

Use whatever format you want, SBAR or whatever, but if you appear organized and knowing the situation and what you want to do about it, you will have more success with on call physicians. If you just describe situations and say, "Well, what do you want to do about it?" then you are going to get silly questions from MDs.

LovingLife123 · May 21, 2017

Was it possible she was asking about what her vital signs looked like? I will often report to the MD that the pt gets tachy and BP is rising with increasing pain. That to me would be what that means.

macawake, MSN · May 21, 2017

This could be a fun topic.

You had a stage 4 cancer patient who didn't get adequate pain relief. I fail to see the fun in that.

All I got from the on call doc was "does she look like she's in pain?". She never did put any new orders in. This is bugging the heck out of me. Not so much that there were no new orders put in. I get it if you think the pt's a drug seeker and you don't want to prescribe, but since when are med orders determined by whether the nurse thinks the pt looks like they are in pain?

It doesn't bother you that no new orders were put in? Your terminally ill patient had pain that her current meds didn't touch and you allowed the on call physician to do nothing to help the patient? Unless you've left out a lot of details from your post, it seems like you completely failed to advocate for your patient. I know I sound judgmental. I am being judgemental of the way you handled this. The fact that the physician asked a rather odd question, shouldn't have resulted in your patient not receiving effective pain relief.

Who cares if your patient "looked like", or didn't "look like" she was experiencing pain. When a stage 4 cancer patient say that they're experiencing severe pain, you believe them. Trying to figure out if they're "drug seekers", has no place in this specific context. That's what I would have told any physician who questioned my request for additional pain medication orders, and I think that's what every nurse should do.

MunoRN, RN · May 21, 2017

It's hard to respond without knowing where the conversation went from there. I'm assuming/hoping you asked for clarification about what "does she look like she's in pain" meant. Just based on what we know, it would seem the physician was acting inappropriately if they cut back their baseline pain control to almost 1/4 of what it was in a hospitalized stage 4 cancer patient.

AceOfHearts<3 · May 22, 2017

Another thing to be aware of is making sure the patient doesn't go into withdrawal because the amount of pain medication is so dramatically reduced so quickly. When I started at my new job they went over a formula in orientation to make sure patients are getting enough medication to cover their acute need on top of their chronic pain needs.

This patient went from getting 4mg q4h, so 24mg in a 24 hr period to just 1mg q3 for a total of 8mg. She was getting a third of her normal amount. I'm not an expert on this, but it seems to me she could be at risk for withdrawal- especially if she's been on the meds for a significant period of time.

YoutubeTheNP · May 22, 2017

"does she look like she's in pain" . . .

does the pt look febrile

does the pt look toxic

does the pt look overweight

does the pt look like he's in respiratory distress

It really is an objective question. Not sure why you're all heated about it. Use your clinical skills look at VS, HR, neuro assessment, body language.

Unfortunately acute care isn't really compassionate anymore these days, with exception, mainly due to such high abuse and many patients malingering their symptoms. I see it all the time in the ER. So sick of giving people dilaudid or morphine with negative abdominal pain work ups, etc.

I get your pt was a breast cancer patient, but maybe the physician was just frustrated with the scenario and same ol problem.

macawake, MSN · May 22, 2017

Unfortunately acute care isn't really compassionate anymore these days, with exception, mainly due to such high abuse and many patients malingering their symptoms. I see it all the time in the ER. So sick of giving people dilaudid or morphine with negative abdominal pain work ups, etc.
I get your pt was a breast cancer patient, but maybe the physician was just frustrated with the scenario and same ol problem.

Seriously, do you think that's an acceptable excuse for denying a terminally ill patient adequate pain relief?

I don't care how jaded or burnt out you are, if you reach the point where you can let a verifiably gravely sick human being suffer when you have the means to alleviate that suffering, it's time to have a long vacation or a change of career.

@AceOfHearts, I hardly ever administer hydromorphone so I don't know the conversion tables offhand. (I seem to remember from pharm class that hydromorphone has large interpatient variability when it comes to bioavailability). Anyway, it is possible that the two doses (PO and IV), due to different bioavailability, are roughly equianalgesic. Either way, the patient wasn't getting the pain relief she needed, so something needed to be done.

YoutubeTheNP · May 22, 2017

Seriously, do you think that's an acceptable excuse for denying a terminally ill patient adequate pain relief?
I don't care how jaded or burnt out you are, if you reach the point where you can let a verifiably gravely sick human being suffer when you have the means to alleviate that suffering, it's time to have a long vacation or a change of career.

You're putting way more context and assumptions into this response then the original story ever gave.

As a cancer survivor I know what it's like to be in pain so I normally dose my cancer pts above average. All I was trying to put in perspective was the possible insight as to why the physician did what he/she did.